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Request to change response to the consent question on the 2006 Census of Population

I authorize Statistics Canada to change my response to the consent question (Question 8 on the short questionnaire/Question 53 on the long questionnaire) for the 2006 Census of Population.

Note: An individual application form must be completed for each household member if request is for two or more individuals.

Please provide the following information in order to facilitate your request. 1. Name
2. Current address
3. Address on May 16, 2006
4. Date of birth (Required for validation purposes only)
5. Phone number
6. Requested change (check applicable box)
I agree to make my Census of Population information available for public release in 2098 (after 92 years have passed).
I do not agree to make my Census of Population information available for public release in 2098 (after 92 years have passed).
7. Signature of applicant*

*If the person for whom information is requested is currently under the age of 16, a parent or legal guardian may sign in his or her place. In all other cases, only the person to whom the information applies must sign.

7. Date

Mail completed form to:

Privacy Coordinator
Statistics Canada
25-B, R.H. Coats Building
100 Tunney's Pasture Driveway
Ottawa, Ontario
K1A 0T6